Every primary care physician (PCP) in the United States should be integrated into an accountable care model. The primary objective of accountable care models is to provide all participating healthcare providers with the necessary incentives and resources to deliver top-notch, coordinated, team-based care that prioritizes health promotion. By doing so, it aims to minimize fragmentation and reduce costs for individuals and the healthcare system as a whole.

The Center for Medicare and Medicaid Innovation (CMS Innovation Center or “Innovation Center”) is embarking on an ambitious new strategy aimed at achieving fair outcomes through the provision of high-quality, ...

Recently, we have been getting questions about the new Healthcare Common Procedural Coding System (“HCPCS”) code G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition).

This code went into effect for The Centers for Medicare and Medicaid Services (“CMS”) on 1/1/2024.

As you can see from the description of the code, there is a lot to unpack ...

If you have questions about how to properly bill Medicare for bilateral procedures, the National Correct Coding Initiative (“NCCI”) policy manual has your answers. Starting on page 30 of chapter 1 of the 2024 NCCI manual, they give detailed instructions.

Step one – Look your code up in the Medicare Physician Fee Schedule Database (“MPFSDB”). Don’t know where to find the MPFSDB? No worries, we have you covered. The most direct way is to go to the Centers for Medicare and Medicaid Services’ (“CMS”) website and use their Fee Schedule Tool which is included the references section below. Follow these steps ...

In this series of articles on the National Correct Coding Initiative (“NCCI”) Policy Manual, we have discussed procedure to procedure (“PTP”) edits and medically unlikely edits (“MUE”), but were you aware that NCCI also has add-on code (“AOC”) edits?

Add-on codes are codes that should not be reported alone. They will always be billed as an “add on” to a primary code. The Current Procedural Terminology (“CPT”) manual will indicate add-on codes with a “+” sign.  They may also give a list of primary codes that the add-on code can be reported in addition to.

Most ...

Introduction & Background

Following the enactment of the Patient Protection and Affordable Care Act (PPACA) in March 2010, the healthcare industry has experienced a major shift in its reimbursement and payment structure. While the United States healthcare system had historically operated under a fee-for-service (FFS) model, the PPACA initiated a notable shift to value-based care (VBC). Under the traditional FFS model, providers are paid separately for each medical service. Because of this structure, the FFS model has been characterized as a ‘volume-based’ payment model, under which healthcare expenditures notably increased. Many argue that this outcome ...

In part one we discussed procedure to procedure (“PTP”) edits. In this article we will discuss Medically Unlikely Edits (“MUEs”).

The Centers for Medicare and Medicaid Services (“CMS”) defines an MUE as “the maximum units of service reported for a HCPCS/CPT code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service.”

There are two types of MUEs, Claim line MUEs and date of service MUEs. This may just sound like semantics, but it really matters.

A claim line MUE is adjudicated based on the units billed on the line item ...

Introduction

March is Kidney Awareness Month, and Pinnacle wants to share updates regarding the new conversion from v24 to v28.  What better way to celebrate than to brush up on how kidney and underlying kidney related diseases affect Risk Adjustment!? As we move forward over the next three-year implementation, it is important to understand how this new model will affect everything we know about Medicare Advantage and Risk Adjustment.

Chronic kidney disease (“CKD”), also known as chronic kidney failure, is a condition in which kidney function gradually declines. In its early stages, symptoms may not be ...

In the introduction, we discussed the three (3) edit types that make up the National Correct Coding Initiative (“NCCI”). Probably the most familiar of those edits are the procedure to procedure (“PTP”) edits, which bundle two codes together.

Don’t be tempted to underestimate this edit type. A common misconception is if two codes are bundled, you can just add a modifier 59.

First, there are quite a few “unbundling” modifiers. Modifier 59 should be the modifier of last resort.

Other NCCI unbundling modifiers are the anatomical modifiers (E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, ...

One of the best resources we frequently recommend to providers is the National Correct Coding Initiative (“NCCI”) policy manual. It is like using a crystal ball to peer into the mind of CMS. The policy manual explains why CMS has edits that bundle two codes together, or why CMS limits how many units of a particular code you can bill. More importantly, the manual explains when it is appropriate to override these edits and how to do it correctly.

This manual serves as a toolkit for providers, coders, and billers alike.  We recommend dedicating specific time to ...